Latest Updates

Cardiovascular System: Heart Diseases

    • MRI safe devices and leads: older implanted devices were considered an absolute contraindication for MRI, depriving patients of the benefits of this important diagnostic imaging modality. Although many of the fears of device malfunction during MRI have been shown to be unfounded, newer devices and leads have been manufactured to ensure safety within the MRI scanner.
    • Leadless pacemakers: a recent innovation is the implantation of miniaturised pacemakers directly into the myocardium, avoiding the need for pacemaker leads.
    • Recent studies suggest improved outcomes by novel cardiac resynchronization therapy pacing modes (LV only modes).
    • Device innovation for MAZE procedures: technologic advances allow reduction of invasiveness of MAZE procedures, such as robotic-assisted procedures, or translate advances in energy delivery developed in transcatheter ablations to the surgical world (cryoMAZE).

The Post-Anesthesia Care Unit

Evan R Bohnenblust, MD
    • When proper monitoring and dosage is used, the incidence of residual neuromuscular blockade is greatly reduced when sugammadex is administered as a reversal agent. (Brueckmann B, Sasaki N, Grobara P, et al. Effects of sugammadex on incidence of postoperative residual neuromuscular blockade: a randomized, controlled study. Br J Anaesth 2015;115:743–51).
    • In patients who have undergone neuraxial anesthesia for lower extremity joint surgery, fast-track discharge from PACU (discharge prior to return of motor function) may significantly reduce total PACU time and is not associated with increased length of stay or 30-day readmission. (Aasvang EK, Jørgensen CC, Laursen MB. Safety aspects of postanesthesia care unit discharge without motor function assessment after spinal anesthesia: a randomized, multicenter, semiblinded, noninferiority, controlled trial. Anesthesiology 2017;126:1043–52).
    • Important risk factors for early PACU delirium may include age, male gender, longer preoperative fasting, higher ASA score, the use of benzodiazepines, opioids, and volatile anesthetics, and transfusion of red blood cells or fresh frozen plasma (Hernandez BA, Lindroth H, Rowley P, et al. Post-anaesthesia care unit delirium: incidence, risk factors and associated adverse outcomes. Br J Anaesth 2017;119:288–90).
    • In patients undergoing major intra-abdominal surgery, the Surgical Apgar Score may provide an objective scoring system to predict the need for postoperative ICU admission (Sobol JB, Gershengorn HB, Wunsch H, et al. The surgical Apgar score is strongly associated with intensive care unit admission after high-risk intraabdominal surgery. Anesth Analg 2013;117:438–46).

Nonpulmonary Thoracic Procedures

Jaida C Fitzgerald, MD
    • Compared to open surgery, minimally invasive surgical approaches for esophagectomy have been associated with less blood loss as well as shorter length of stay at intensive care unit and the hospital.
    • Implementation of thoracic epidural analgesia for post esophagectomy pain control has been shown to result in earlier mobilization, decreased incidence of pulmonary complications, and decreased incidence of anastomotic leaks.
    • There is a decreased incidence of respiratory complications with the intraoperative use of lung protective strategies during esophagectomy.

Carotid Endarterectomy

Louisa Palmer, MD, Amanda Widing, MD,1 PGY-3 Resident
    • Increased focus on patient selection with respect to 3- to 5-year predicted survival
    • Improvement in medical management including preoperative optimization and updated decision support for preoperative cardiac testing
    • Improvement in outcomes after carotid artery stenting makes it a reasonable alternative to carotid endarterectomy
    • Increased prevalence of ultrasound-guided techniques for deep and superficial cervical plexus block
    • Investigation of use of transcranial Doppler for detection of carotid thrombosis and early hyperperfusion syndrome

Allergic Response

    • Antihistamines to block the binding of histamine at target sites, aspirin and NSAIDs to block the synthesis of prostaglandin D2, and leukotriene antagonists blocking it’s downstream effects
    • Allergen immunotherapy to induce long-lasting clinical tolerance in sensitized patients in an antigen-specific approach
    • Monoclonal antibodies against IL-5 (mepolizumab, reslizumab), and IL-5 receptor (benralizumab) for treatment of hypereosinphilia and proposed for allergy diseases

Wide Complex Tachycardia

Sally Graglia, MD, Gary Green, MD
    • An unstable patient with wide-complex tachycardia may be approached with the usual advanced cardiac life support algorithms: high-quality chest compressions and defibrillation in pulseless patients and synchronized cardioversion in patients with a pulse.
    • Recent data suggest limited utility of Advanced Cardiac Life Support interventions (medications, advanced airway) compared with basic life support, reminding providers to focus on effective cardiopulmonary resuscitation and defibrillation (avoiding implantable cardioverter-defibrillator or pacemaker devices).

Sclerotherapy

Khalil H. Chamseddin, MD, Melissa L Kirkwood, MD
    • Polidocanol is now FDA approved in a foam formulation
    • Correction of axial great spahenous vein reflux first is essential for optimal success of venous sclerotherapy treatments
    • Venous duplex ultrasonography has revolutionized the treatment of varicose and spider veins.
    • Sclerotherapy is reproducible and noninvasive and can objectively identify areas of reflux in the great and small saphenous systems, as well as detect pathologic conditions in the deep venous system and incompetent perforating vessels. Sclerosants may be classified into three main categories: hypertonic solutions, chemical irritants, and detergents.
    • The detergent class of sclerosants form aggregates on endothelial cell surfaces and cause endofibrosis by disrupting the integrity of the cells. Polidocanol (POL) is the most commonly used sclerotherapy agent worldwide. Sodium tetradecyl sulfate (STS) is also a commonly used agent in the United States; both POL and STS are approved by the FDA.

Allergic Response

    • Antihistamines to block the binding of histamine at target sites, aspirin and NSAIDs to block the synthesis of prostaglandin D2, and leukotriene antagonists blocking it’s downstream effects
    • Allergen immunotherapy to induce long-lasting clinical tolerance in sensitized patients in an antigen-specific approach
    • Monoclonal antibodies against IL-5 (mepolizumab, reslizumab), and IL-5 receptor (benralizumab) for treatment of hypereosinphilia and proposed for allergy diseases
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